Surgical findings show important alterations of the extrinsic and intrinsic vascularity of the ulnar nerve in the epitroclear groove. Current procedures are only able to solve the mechanical aspect of nerve compression. Transposition may cause additional iatrogenic ischaemic damage of endoneural vascularity if the nerve is separated from the ulnar collateral artery to achieve anterior mobilization. Our technique of transposition of the ulnar nerve with its vascular bundle maintains the advantages of anterior transposition currently in use, but is able to preserve the whole vascularity of the nerve, thus solving the biological aspect of nerve compression. This allows quicker recovery of axonal activity that was chronically compromised by the entrapment neuropathy. The technique and the results in 30 patients (90% excellent and good, 10% fair) treated since 1987 are presented.
Continuous extension of Dupuytren's contracture prior to fasciectomy results in a softening of the tissue, allowing straightening of the fingers. The observed change in cross-link profile indicates an increase in newly synthesised collagen due to increased turnover. This was confirmed by demonstration of the increases in levels of the degradative enzymes, the neutral metalloproteinases, collagenase and gelatinase and the acidic cathepsins B and L. Both types of enzyme effectively depolymerize the collagen fibres, albeit by different mechanisms, leading initially to loss of tensile strength and ultimately to solubilization. We suggest that the increase in enzyme activity is generated by tension on the fibroblasts of this metabolically active tissue produced during the continuous extension of the retracted fingers. The weakening of the fibres by degradation and the increase in newly synthesized collagen provide an explanation for the extension of the tissue without trauma.
After complete elongation using the continuous extension technique the palmar fascia of four patients with Dupuytren's contracture was examined by light and electron microscopy and compared with non-elongated samples from 20 patients at the same clinical stage of the disease. Nodules and cords were no longer clinically recognizable after extension. The tissue contained collagen fibrils of uniform diameter (about 50 nm), densely packed in fibres parallel to the stretching force. Fine filaments (presumably proteoglycans) formed a network which was intermingled with and periodically bound to the collagen fibrils. Fibroblasts and myofibroblasts with an high biosynthetic activity and oxytalan-like microfibrils were aligned along the collagen fibres. The results show that in Dupuytren's disease the contracted palmar fascia reacts to external forces with neoformation and reorientation of all tissue components by myofibroblasts.
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